John C. Kulis Charitable Foundation Grant Application Form

Transcription

1 Review Internal use ONLY: this box completed by the Board Application Received: Initial Review of Submissions: JAK SML Final & Full Review: JAK SML WAS SW Submitted to Board: APPROVED: DENIED: John C. Kulis Charitable Foundation Grant Application Form Instructions The Board of the John C. Kulis Charitable Foundation annually meets in the Fall to consider Grant Applications. In order to be considered for a grant, this Grant Application Form must be completed in its entirety and submitted with ALL checklist items before July 1. Grant Applications submitted by July 1 will receive a written notification of a decision by December 1. Grant Application Awards are issued in the calendar year following the submission of the completed Grant Application Form. You may submit additional materials to supplement your Application Form, however additional/ supplemental materials will not be accepted or reviewed in lieu of a fully-completed Grant Application Form. If your answer to any questions on the Grant Application Form requires more room than is available, please attach a sheet of paper as a continuation and reference the Section and Subsection (e.g. II, D ) for your continued answer. Checklist & Additional Information/Documents Fully-completed Kulis Foundation Form Certified/signed Release of Information & Agreement (page 7 of 7) A copy of the Organization s latest Form 990, 990EZ or 990-P (Return of Organization Exempt from Federal Income Tax) A copy of the Organization s IRS 501(c)(3) determination letter or evidence of an affiliation with a 501(c)(3) organization. * * Organizations within a church, which is directly affiliated with a hierarchal church, are not required to submit a determination letter or evidence of the affiliation. A copy of at least two (2) years of your Organization s annual financial reports, including the annual audit/audited financial statements, if such audit(s) exist. A formal, separate Grant Proposal, which includes: 1) Project/Program Abstract; 2) a Statement of Need; 3) the Program/Project Description; 4) Goals & Objectives; 5) a Timeline; 6) the Budget; 7) Evaluations; 8) Staff and Organizational information; and 9) an Appendix. See Section III. B. of this Grant Application Form. Page 1 of 7

2 I. Organization s Contact & Summary Information A. Organization s Information Organization s Name Organization s Street Address Organization s City, State ZIP Organization s Phone No.: Organization s Fax No.: Organization s webpage: Date Organization granted 501(c)(3) status from IRS: FEIN #: Parish Priest s Name: Organization s Chief Executive Officer / President s Name & Title (e.g. CEO or equivalent): Organization s Chief Financial Officer / Treasurer s Name: B. Information for Organization s Contact Person Contact s Name: Contact s Title Contact s Office No.: Contact s Cell No.: Contact s Fax No.: Contact s Address: C. Summary Request General Purpose of Grant Request: Total Cost of Project/Program (in US): Amount Sought (in US) from the Kulis Foundation: Date Funds are required: (e.g. capital improvement, programing/education, matching fund) Percent Funded by Kulis % Form CGA, Ver Page 2 of 7

3 II. Organization s Mission, Structure & Support A. Organization s Mission Statement Copy the Organization s full Mission Statement here. B. Furtherance of Mission Statement How does the Organization further its Mission? C. Affiliation with the Orthodox Church Is the Organization a part of the Greek Orthodox Church of America, the American Carpatho-Russian Orthodox Church, the Ukrainian Orthodox Church of America, or an agency of the Assembly of Bishops? Does your Organization provide services or programs to these or other Orthodox Jurisdictions? Please specify. D. Support of the Greek Community Does the Organization advance, support or protect the interests of the Greek community in the United States or in Greece? If so, please specify. E. Additional Information about the Organization List any history, achievements, hardships, need(s), or other information to provide perspective as to the Organization, its background and how the Organization furthers its Mission. Form CGA, Ver Page 3 of 7

4 F. Organization s Board of Directors (and tenure if available) that Decide, Guide and Oversee Board Title Name & tenure G. Support from the Organization s Board of Directors Does the Organization s Board of Directors support the Mission and efforts of the Organization through their time, talent and treasure? If so, please specify. H. Organization s Officers (and tenure if available) Authorized to Implement the Decisions, Directions and Oversight from the Board of Directors Officer Title Name & tenure I. Support from the Organization s Officers Does the Organization s Officers support the Mission and efforts of the Organization through their time, talent and treasure? If so, please specify. Form CGA, Ver Page 4 of 7

5 III. Proposed Project / Program A. Project(s) / Program(s) Information Program / Project Title: Proposed start date: Projected completion/end date: Total Cost of Purpose/Project (in US) (same from p.1): Amount Sought (in US) from Kulis Foundation (same from p.1): B. Formal Grant Proposal Percent Funded by Kulis % Please prepare and attach a formal, separate Grant Proposal for the program(s)/project(s) that the Organization will use the Kulis Foundation s Charitable Grant. Describe how the Grant will further the missions of both the Organization and the Kulis Foundation. The formal, separate Grant Proposal must include the following sections with corresponding information: 1. Program/Project Abstract. The project abstract must include a succinct summary of the program/project, which is no longer than one page. The abstract should describe the need for the project, the population it will serve, a brief description of the project and its goals and objectives, as well as the applicant s background and qualifications. Please include the amount of funding your organization seeks. Lastly, explain how the program/project will be evaluated by your organization to measure the success of the program/project. While at the beginning of the Formal Grant Proposal, the abstract should be the last portion of the separate, formal Grant Proposal that your organization drafts. 2. Statement of Need. The statement of need must explain the problem or circumstance that the program/project will attempt to address, including a description of the population the program/project will serve. 3. Program/Project Description. Describe the program/project and provide information on how your organization will implement it, including information on what the organization will accomplished and the desired outcome. 4. Goals & Objectives. Detail the project objectives in measurable terms that address the Statement of Need. 5. Timeline. Include past dates from preparation and submission of the Grant Application and future projected dates from: desired receipt of grant funds; implementation of the program/project and any described phases or steps; anticipated milestones or deadlines for interim goals and objectives; through to the completion of the program/project. 6. Budget. Include a detailed financial budget of all expenses and revenue sources, if applicable, for your program/project. Mention any co-funding that you are using from other sources. You may want to include a brief narrative of expenses along with a table of individual cost components. 7. Evaluation. Provide information on the metrics that will be used to analyze, measure or otherwise determine the effectiveness of the program/project. Form CGA, Ver Page 5 of 7

6 8. Staff and Organizational Information. Include the staff qualifications, certifications, and skills of those individuals who will become involved with the program/project, and describe the organization s capacity to implement and sustain the program/project. 9. Appendix. Attach relevant items in the Appendix including letters of support, research support, organizational collateral, proof of non-profit tax status, annual reports, audits, etc. C. Other Potential Funding Sources Considered for the Project / Program Please indicate whether the Organization has considered funding from other private or public sources to pay or finance the Project(s)/Program(s). Source Considered for Funding Amount Considered () Expected Decision Date D. Other Funding Sources Received for the Project / Program Please indicate whether the Organization has received funding from other private or public sources to pay or finance the Project(s)/Program(s). Source of Funding Received Amount Received () Date Received E. Future Funding If the Project/Program will continue beyond the Kulis Foundation s Charitable Grant amount/period, please describe plans for future funding of the Project/Program upon depletion/end of the Charitable Grant. Form CGA, Ver Page 6 of 7

7 IV. Release of Information & Agreement Please certify by signing below: The Undersigned, a duly-authorized agent of the applicant Organization listed herein, authorize the Kulis Foundation to release information contained in this grant application, including copies of the submitted form and any accompanying attachments ( Grant Application ), to the Kulis Foundation s Board, its Officers and Grant Committee or any agent(s) thereof (collectively the Kulis Foundation ). I agree that the Kulis Foundation may verify any and all information included herein or provided in support of this Grant Application, which may include pertinent personal and financial information. The Kulis Foundation is authorized to contact any individuals listed herein to confirm or discuss the information disclosed in the Grant Application. I hereby certify that the information provided in this Grant Application is true, accurate and complete, and that I either authored, or reviewed and fully approved the submission of information authored by other individuals authorized to do so on behalf of the Organization. I understand that if any information herein is found to be inaccurate or incomplete, the Kulis Foundation will deny our Organization a grant. I further understand that submission of even a fully-completed Grant Application does not guarantee the Kulis Foundation will award a Charitable Grant, which may only be done in the absolute discretion of the Kulis Foundation. If awarded a Kulis Foundation Charitable Grant, I authorize the Kulis Foundation to publicize the Organization as a recipient. I understand the Kulis Foundation will not release the Organization s financial information to the general public. If a grant is awarded, the Organization agrees to use the funds only for the purposes for which the grant was made and acknowledges the Kulis Foundation s authority to withhold or recover grant funds if an investigation reveals the funds have been misused. In addition, I understand and agree that the Organization is required to provide periodic written reports describing the status of the program and provide an accounting of the funds used to date as well as plans for use of the remainder of funds. I also agree to provide a final, written report and an accounting explaining specifically how grant funds were actually used. By: Signed, on behalf of the Organization By: Printed, on behalf of the Organization Title with the Organization Date Form CGA, Ver Page 7 of 7